The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

hyperglycemia

Urinary retention

Respiratory failure

Hypertension

Answer and Explanation

The Correct Answer is C

A. Hyperglycemia:
Although hyperglycemia can occur as a result of stress or corticosteroid use during the treatment of GBS (such as in the case of plasma exchange or IV immunoglobulin (IVIG) therapy), it is not the primary complication associated with GBS. While hyperglycemia requires monitoring and management, respiratory failure is a more immediate and critical concern.

B. Urinary retention:
Urinary retention can occur in some clients with neurologic disorders like GBS, but it is not as life-threatening as respiratory failure. The autonomic nervous system, which controls bladder function, may be affected, but urinary retention is usually manageable with intermittent catheterization or other interventions. It does not carry the same immediate risks to life or organ function as respiratory failure.

C. Respiratory failure:
In Guillain-Barré syndrome (GBS), the immune system attacks the peripheral nervous system, which can lead to progressive muscle weakness and paralysis. The most significant and potentially life-threatening complication of GBS is respiratory failure. This occurs because the paralysis can affect the muscles involved in breathing, including the diaphragm and intercostal muscles, leading to impaired ventilation. As the weakness progresses, the client may become unable to maintain effective breathing, requiring mechanical ventilation. Monitoring for signs of respiratory distress (e.g., increasing work of breathing, tachypnea, decreased breath sounds, or a drop in oxygen saturation) is critical in GBS, especially during the acute phase of the disease.

D. Hypertension:
Hypertension may be seen in some cases of GBS, particularly during the early stages of the disease, due to the autonomic dysfunction that can result from nerve involvement. However, hypotension (low blood pressure) is more commonly associated with the autonomic dysfunction in GBS rather than hypertension. Regardless, respiratory failure remains the most urgent complication to monitor for in clients with GBS.

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Correct Answer is C

Explanation

A) pH 7.32, PaO2 88 mmHg, PaCO2 50 mmHg, HCO3 29 mEq/L, O2 sat 94%
This result suggests respiratory acidosis rather than respiratory alkalosis. In respiratory acidosis, the pH would be low (acidotic), PaCO2 would be elevated (since it reflects CO2 retention), and HCO3 would typically be elevated as a compensatory mechanism. This set of ABG values does not align with respiratory alkalosis, so it is not consistent with partially compensated respiratory alkalosis.

B) pH 7.35, PaO2 98 mmHg, PaCO2 55 mmHg, HCO3 28 mEq/L, O2 sat 99%
This set of values suggests respiratory acidosis, as indicated by a low pH (acidosis) and high PaCO2 (carbon dioxide retention). The HCO3 value is slightly elevated in compensation for respiratory acidosis, but this is not an example of partially compensated respiratory alkalosis, so it doesn't match the question's requirement.

C) pH 7.64, PaO2 94 mmHg, PaCO2 23 mmHg, HCO3 14 mEq/L, O2 sat 88%
This result is consistent with partially compensated respiratory alkalosis. In respiratory alkalosis, the pH would be elevated (alkalotic), PaCO2 would be low (indicating hyperventilation), and the kidneys would attempt to compensate by lowering bicarbonate (HCO3). In this case, the low PaCO2 (23 mmHg) and the low HCO3 (14 mEq/L) demonstrate partial compensation. The pH is also elevated at 7.64, which aligns with alkalosis. This is the correct answer for partially compensated respiratory alkalosis.

D) pH 7.50, PaO2 91 mmHg, PaCO2 52 mmHg, HCO3 30 mEq/L, O2 sat 96%
This result suggests respiratory acidosis with compensation. The elevated PaCO2 (52 mmHg) indicates CO2 retention, leading to acidosis, while the slightly elevated HCO3 (30 mEq/L) shows that the kidneys are compensating for the respiratory acidosis. The pH of 7.50 is slightly alkalotic, but it is more consistent with compensation for respiratory acidosis rather than respiratory alkalosis. Thus, this set of ABG values does not match the description of partially compensated respiratory alkalosis.

A. Monitor the client's pulse oximetry every shift B. Assess the client's respiratory status at least every 1-2 hours C. Ensure that a manual resuscitation bag is at the bedside D. Check the ventilator settings every shift E. Collaborate frequently with the respiratory therapist

Correct Answer is ["B","C","D","E"]

Explanation

A) Monitor the client's pulse oximetry every shift:
Monitoring pulse oximetry every shift is not sufficient when caring for a client on a ventilator. Pulse oximetry provides valuable information about oxygen saturation, but it should be checked more frequently, especially in a critically ill patient on a ventilator. Continuous monitoring may be required to ensure that oxygenation is maintained at optimal levels. The nurse should assess the pulse oximetry regularly and take immediate action if there is a significant change in the client’s oxygen saturation.

B) Assess the client's respiratory status at least every 1-2 hours:
It is essential to assess the client's respiratory status frequently when they are on a ventilator. Respiratory assessments should be performed at least every 1-2 hours to monitor for complications such as ventilator-associated pneumonia, changes in oxygenation, or the need for adjustments to the ventilator settings. Regular assessment is critical to detect early signs of deterioration and respond promptly.

C) Ensure that a manual resuscitation bag is at the bedside:
Having a manual resuscitation bag (e.g., Ambu bag) at the bedside is a critical intervention for clients on a ventilator. In case of ventilator malfunction, extubation, or respiratory distress, the nurse must have immediate access to a resuscitation bag to manually ventilate the patient. This is a lifesaving piece of equipment that should always be present and ready for use.

D) Check the ventilator settings every shift:
It is essential to check ventilator settings every shift to ensure that the ventilator is functioning correctly and providing the appropriate levels of support for the patient. This includes checking settings such as tidal volume, respiratory rate, pressure, and FiO2 (fraction of inspired oxygen) to ensure they are appropriate for the client's condition. Regular checks can help detect problems such as changes in settings or malfunctioning equipment.

E) Collaborate frequently with the respiratory therapist:
Frequent collaboration with the respiratory therapist is crucial when managing a client on a ventilator. Respiratory therapists are experts in ventilator management and can provide valuable insight into adjusting settings, interpreting ABGs, troubleshooting equipment issues, and optimizing respiratory care. Collaborative care helps ensure that the client is receiving the most appropriate interventions and adjustments for their respiratory status.

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The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is ["B","C","D","E"]

Explanation

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